Mechanical ventilation practice has changed over time; as new insights are provided by scientific research, so traditional modes of ventilation are being revised. In patients with acute lung injury (ALI) mechanical ventilation with lower tidal volumes contributes to patient survival, most likely by preventing ventilator-associated lung injury. In contrast, patients without ALI are still subjected to traditional ventilation modes using higher tidal volumes. Studies on ventilator-associated lung injury in subjects without ALI demonstrate inconsistent results. However, retrospective clinical studies suggest that higher tidal volumes increase the risk of developing lung injury. Moreover, even short-term mechanical ventilation seems to induce a pro-inflammatory response locally in the lungs, which can be limited by the use of lower tidal volumes. Conversely, the use of lower tidal volumes in patients has been associated with minimal adverse events. We propose that regardless of pre-existent lung injury, all patients in need of respiratory support should be ventilated with lower tidal volumes (i.e. 6 mL/kg ideal body weight), thereby preventing ventilator-associated lung injury. Prospective studies in both the operating rooms and intensive care units should be performed to evaluate optimal ventilator management strategies for patients without ALI. Copyright © 2008, Nederlandse Vereniging voor Intensive Care. All Rights Reserved.